Hindsight is nearly always 20/20. In the case of the recently updated Healthy People Initiative metrics, hindsight can also be used as a tool for shaping the future. Specifically, by taking stock of current health metrics, this initiative can serve as a platform for change.¹ The Healthy People Initiative, overseen by the Department of Health and Human Services, sets a national health agenda for each decade, broken down into disease-specific parameters along with pre-specified targets in the domains of prevention, outcomes and systems of care. The category of Heart Disease and Stroke (cardiovascular disease, CVD) comprises 50 of these objectives.

A report recently published in Circulation described the current status of the Healthy People 2020 (HP2020) CVD objectives.² The timing of most recent data collection varies among objectives (between 2014 and 2017 for most) as this is dependent on the timing of follow-up for source cohorts. At most recent assessment, 14 of the 37 measurable CVD objectives (those with existing baseline data) had already reached the 2020 targets and 7 more are on track to meet their targets in time.

A closer look at the data, however, reveals an important trend. Outcomes for clinically evident CVD are improving due to advances in treatment of acute disease. However, there is a lack of improvement in underlying risk factor burden, which, unless addressed now at a primordial stage, will result in regrowth in CVD burden in upcoming decades.

Success in Health Systems Collaboration

Thrombolytic and percutaneous intravascular interventions revolutionized the management of coronary and cerebrovascular events in the twentieth century. A major accomplishment of the most recent decade is the optimization of these therapies by implementing them in a timely fashion. HP2020 metrics with significant improvement include achievement of a door-to-balloon time for ST-elevation myocardial infarction of less than 90 minutes and reperfusion therapy for stroke patients within 3 hours.

Meeting these metrics has required improvements in public health awareness regarding symptoms of these life-threatening conditions (itself an HP2020 metric) as well as strategic coordination of care among multidisciplinary departments and between regional institutions and emergency transport organizations. These important innovations should be celebrated, particularly in light of the associated reduction in coronary heart disease and stroke deaths.

Nonetheless, it is sobering that for all of the efforts made to implement life-saving interventions, the nation has regressed in referring heart attack survivors to cardiac rehabilitation, an intervention which is proven to improve cardiovascular mortality, reduce hospital admissions and improve quality of life.³ We have enabled more people to survive to hospital discharge – now let's take the next step in equipping our patients to thrive in the additional years of life provided by PCI and modern medical therapy.

Opportunities for Growth: Preventive Practices

Both the population with known coronary heart disease and those with history of stroke still fall below HP2020 targets for meeting LDL-cholesterol (LDL-C) goals, with no evidence of improvement since baseline values were recorded in 2008 (51% and 43%, respectively, were not at goal in 2014). What's more, the LDL-C target used for these metrics is <100 mg/dL. As the most recent guidelines set an LDL goal <70 mg/dL for high-risk groups based on evidence demonstrating that lower is generally better, even fewer have likely truly optimized this risk factor.⁴ The new guidelines and this HP2020 report can serve as an excellent catalyst for initiating renewed conversations with patients about starting and intensifying lipid-lowering therapy.

Among adults with hypertension, slight improvements since HP2010 were observed in the percentage taking antihypertensive medication (67%, with a goal of 70% for HP2020) and those in whom hypertension is under control (48% with a goal of 61% for HP2020), yet this still falls short of the progress hoped to have been attained by 2020.

The area with the most marked room for improvement is in the implementation of guideline-directed lifestyle interventions in this population. There has been no improvement in the percentage of hypertensive adults meeting physical activity guidelines (from 28% in 2010 to 31% in the most recent HP2020 report) and regression in the percentage who have normal BMI (from 18% in 2008 to 14% in HP2020). Among those with the now-outdated designation of pre-hypertension who arguably have the most to gain from early lifestyle changes, the statistics are similar—no improvement in physical activity (41% of target in HP2020) and BMI (26% of target in HP2020) parameters.

There is a significant room to improve practice patterns in preventive care, but sometimes the system fails us. A closer look at the tobacco use statistics (reported separately from the HDS data) reveals an intriguing dichotomy: we have made strides at reducing rates of cigarette smoking, particularly among adolescents; however, little progress has been made in securing Medicaid coverage of evidence-based tobacco cessation therapy, with only 11 states now offering such coverage, compared with six in 2008.

Additionally, it is no surprise that disparities exist among cardiovascular risk factors and outcomes. The HP2020 report adds further support to the need for more intensive resource allocation and creative public health interventions for geographic and racial/ethnic groups with traditionally worse health cardiovascular health parameters, including Latinos, non-Hispanic black individuals and those living in non-metropolitan settings.

However, there are also signs of hope. Much emphasis has been placed recently on the role of primordial prevention, and the percentage of children and adolescents with hypertension has improved, from 3.5% in HP2010 to 2.2% in HP2020.

2020 and Beyond: Strategies for Emphasis on Preventive Health

Patterns of change in the HP2020 targets described above reflect the experience of many trainees: there is often more focus on damage control than on the promotion of healthy habits. In today's busy practice environment, prioritizing preventive health assessment, counseling and intervention is challenging.

Clinicians and practice administrators can start by taking advantage of the resources available. The authors of the HP2020 update focused particularly on improving control of hypertension at a population level, the single CVD parameter out of the 37 targets in HP2020 that was given the highest level of priority by being marked as a "Leading Health Indicator". The Centers for Disease Control (CDC) curates an online communications toolkit for hypertension control to empower professionals to educate their patients without the time-investment of generating their own material. The page, which includes graphics, full-page handouts, animations and ready-to-publish social media posts with digestible bits of information, is available at https://www.cdc.gov/bloodpressure/communications_kit.htm. Counterparts exist for lipid management, stroke, and nutrition as well.

The Million Hearts Initiative has an objective to connect all stakeholders in the arena of improving cardiovascular health nationwide. Their webpage has a free "Change Package" (https://millionhearts.hhs.gov/tools-protocols/action-guides/htn-change-package/), which provides leaders of outpatient practices a road map to improving hypertension control practice-wide. This includes evidence-based guidelines, practical protocols and tried-and-proven methodology from those who have successfully addressed these needs.

Each year, practices from across the spectrum of size, socioeconomic population served and geographic location are chosen as Million Hearts Hypertension Control Champions for improving hypertension control in their population. Their testimonials describe strategies that can be adopted by others to fit their own practice patterns. Themes that emerge include automated messaging from specialty clinics to primary care providers about elevated readings, pre-specified care pathways, no-cost walk-in blood pressure checks, optimizing use of mobile technology, engagement among non-physician staff, mobile clinics for impoverished and undocumented patients, emphasis on low-cost medications and simple regimens and positive reinforcement.

An often-cited 2009 study assessed that out of every 100 prescriptions written, only 48-66 were actually filled, 25-30 were taken as prescribed, and only 15-20 were refilled as indicated.⁵ As clinicians, we spend a great deal of energy considering our choice of medications for patients, including indications, efficacy evidence, potential side effects and interactions. This statistic serves as a reminder that this time investment is fruitless in the absence of increasing efforts as a multidisciplinary team to identify and address sources of non-adherence (be it to lifestyle or pharmacologic recommendations).

Such practical efforts may become the most powerful impact on a person's long-term health outcome. At the heart of longitudinal medical care is patient empowerment. What is accomplished in a single encounter is not a lasting intervention. An office visit may be more appropriately viewed as a means of equipping our patients to optimize their health and disease management on a daily basis.

Looking Towards 2030: The Metrics

HP2020 established health metric targets for a snapshot in time (the year 2020). We can expect emphasis, goals and allocation of national resources to evolve along with evidence and current needs. Thus, some specific parameters are expected to change in HP2030. The population in need of aspirin prescription for primary prevention will likely narrow in response to 2019 AHA/ACC guideline for the primary prevention of CVD recommendations and recent trials calling into question the efficacy of aspirin for this purpose.^6-10 New HP2030 objectives tracking dietary sodium are also in development, given its widely recognized relationship to hypertension and heart failure, though future studies may be needed to determine the truly optimal daily sodium intake.^11,12

The changing definition of hypertension itself will also re-categorize many individuals for the purpose of these metrics. Finally, the authors of the current report discussed development of the ideal prevention parameter in future iterations of the healthy people reports. This would track the percentage of patients who embody "ideal cardiovascular health," attained by not only avoiding cardiovascular risk factors, but also displaying optimal values for all of the American Heart Association's "Life's Simple 7" cardiovascular health metrics.^13,14

There is also room for the HP2030 targets to set a higher bar. Take, for instance, some of the public health awareness metrics that were reached prior to 2020. HP2020 goals were met for awareness among adults of heart attack and stroke symptoms and the importance of calling 911. The pre-set targets, however, are 41% and 56%, respectively, and leave obvious opportunities for increased public health awareness initiatives. The (developmental) target for individuals with hypertension meeting the recommended daily sodium intake of 1500 mg per day is noticeably low at 1.19%.

Conclusion

The vision of HP2020 is "a society in which all people live long, healthy lives." Individual clinicians, multidisciplinary teams and health care systems across the country have taken sizable and creative strides to improve the health of their clients and deserve commendation. Nonetheless, we cannot rest on our laurels and the HP2020 report highlights areas in need of renewed effort as well.

A controversial 2014 television ad for a childhood obesity initiative opens with a dramatic visual of an overweight young man with a heart attack. The viewer then takes a rapid reverse journey of his life, struggling to keep up with his young children, downing pizza and beer in front of the TV, grabbing sugary cereal on the way out the door to school and finally as a toddler gleefully taking french fries from his parents who express delight at finding something the picky child will eat. The website describes this video as a tool for parents of young children to "fast-forward [your child's life] to show you what the future might look like."¹⁵

Can we use this national report card for cardiovascular health to visualize the future? It has been well publicized that the decades-long trend of improvement in cardiovascular mortality is stalling in this century.¹⁶ Lack of significant improvement across the bulk of preventive health metrics offers an early warning signal of the potential for growing burden of cardiovascular disease and ensuing cardiovascular mortality. HP2020 provides a birds-eye view of specific opportunities to restore a positive trend in line with our shared aspiration: to optimize the health of our patients and communities.

Figure 1

Table 1: Recent Progress for Trackable Objectives for Healthy People 2020 as of January 2019

References

1. US Department of Health and Human Services. Healthy People 2020. Heart Disease and Stroke. https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke/objectives. Accessed May 4, 2019.
2. Pahigiannis K, Thompson-Paul AM, Barfield W, et al. Progress toward improved cardiovascular health in the United States. Circulation 2019;139:1957-73.
3. Anderson L, Oldridge N, Thompson DR, et al. Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol 2016;67:1-12.
4. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASP/NLA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018. [Epub ahead of print]
5. Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation 2009;119:3028-35.
6. Bibbins-Domingo K; U.S. Preventive Services Task Force. Aspirin use for the primary prevention of cardiovascular disease and colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2016;164:836-45.
7. McNeil JJ, Woods RL, Nelson MR, et al. Effect of aspirin on disability-free survival in the healthy elderly. N Engl J Med 2018;379:1499-1508.
8. ASCEND Study Collaborative Group, Bowman L, Mafham M, et al. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Engl J Med 2018;379:1529-39.
9. Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet 2019;392:1036-46.
10. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019. [Epub ahead of print]
11. Mente A, O'Donnell M, Rangarajan S, et al. Associations of urinary sodium excretion with cardiovascular events in individuals with and without hypertension: a pooled analysis of data from four studies. Lancet 2016;388:465-75.
12. Cook NR, Appel LJ, Whelton PK. Sodium intake and all-cause mortality over 20 years in the trials of hypertension prevention. J AM Coll Cardiol 2016;68:1609-17.
13. Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 2010;121:586-613.
14. Al Rifai M, Greenland P, Blaha MJ, et al. Factors of health in the protection against death and cardiovascular disease among adults with subclinical atherosclerosis. Am Heart J 2018;198:180-8.
15. Children's Healthcare of Atlanta, Inc. Rewinding the Future. Strong4Life. 2014. https://www.strong4life.com/en/pages/healthy-eating/videos/rewind-the-future.
16. Sidney S, Quesenberry CP Jr, Jaffe MG, et al. Recent trends in cardiovascular mortality in the United States and public health goals. JAMA Cardiol 2016;1:594-9.

Keywords: Dyslipidemias, Antihypertensive Agents, Cholesterol, LDL, Cardiac Rehabilitation, Prehypertension, Blood Pressure, Risk Factors, Tobacco Use Cessation, Cardiovascular Diseases, Myocardial Infarction, Medicaid, Acute Disease, Outpatients, Healthy People Programs, Body Mass Index, Quality of Life, Hypertension, Myocardial Infarction, Stroke, Centers for Disease Control and Prevention, U.S., Life Style, Coronary Disease, Primary Prevention, Exercise, Primary Health Care, Percutaneous Coronary Intervention, Habits

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